Refueling Assistance Survey
Thank you for taking time to complete this survey.
1. What is your gender?
Male
Female
2. What is your age?
21-25
26-35
36-45
46-55
Over 55
3. What is your disability?
Cognitive
Mobility
Visual
Hearing/Speech
Other
4. How often do you drive?
Not at all
1-3 times per week
4-6 days a week
Everyday
I have someone else drive for me
5. Approximately how many miles do you drive each week on average?
1-10 Miles
11-30 Miles
31-75 Miles
76-100 Miles
More than 100 Miles
6. What is your primary reason for driving?
Getting to/from work
Errands/personal reasons
Travel/leisure
Other (Please specify)
7. Are you able to pump your own gas at service stations or do you require assistance?
Can pump my own
Require assistance
Can pump my own but prefer having assistance
8. Are you aware of the refueling assistance policy set forth by the US Department of Justice?
Yes
No
9. (If you answered yes to question 8) How would you rate the awareness among service station attendants of the current refueling policy?
Poor
Fair
Good
Very Good
Excellent
Non-existent. They do not demonstrate awareness about providing assistance.
10. (If you answered yes to question 8) How would you rate the attitude of service station attendants towards providing refueling assistance?
Poor
Fair
Good
Very Good
Excellent
Non-existent. They do not demonstrate an awareness about providing assistance.
11. What arrangements do you make to ensure that you will have refueling assistance?
Bring a friend/family member with me to pump gas
Ask another customer for fueling assistance
Honk my horn to get the attention of an attendant
Have someone take my car to the station and refuel it
Go to a station where they know me and will always provide assistance
I don't make special arrangements
12. What is your main concern when going to an unfamiliar service station by yourself?
Your personal safety
Giving your credit card to a stranger to pay for the gas purchase
Not being able to get assistance
Other (Specify)
13. Have you ever put off driving/travel plans, by yourself, because of concerns about your ability to get refueling assistance?
Yes
No
14. If you have a particular anecdote or story about refueling challenges that you have faced, please give a brief explanation below of the circumstances and how it was resolved.
Please keep me informed of developments on the issue of refueling assistance.
Yes
No
I would be interested in participating in advocacy efforts by:
Writing/calling my legislators
Meeting with my legislators in Springfield or my district
Enlisting the support of others in my community
First Name
Last Name
Phone
Email Address
*
Indicates Response Required
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